Remaining in HIV Care: Improvements in North America but Much Still Needs to Be Done

Potent combination anti-HIV therapy (commonly called ART or HAART) has greatly reduced deaths from AIDS-related infections in Canada and other high-income countries. The improvements in health brought about by ART are likely to lead to several decades of increased survival for a young HIV-positive person who starts therapy today and who remains engaged in his/her care and treatment.

Issues Remain

Viruses and other germs disturb the immune system, causing activation and inflammation. Such responses by the immune system can be useful when it is initially responding to an infection. However, because HIV becomes a chronic infection and causes long-lasting changes to the immune system, the associated inflammation incited by this virus is only partially dampened by ART. Persistent low-level inflammation may affect the health of key organ systems such as the heart and blood vessels, bones, liver, kidneys and so on. It is therefore important that HIV-positive people, even those who are stable on ART, continue to see their doctors and receive regular medical care, physical exams, blood tests and other assessments, so that any psycho-social or medical conditions that arise can be quickly identified and managed.

Valuable Databases

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In Canada and other high-income countries, thousands of HIV-positive people participate in observational databases. These databases collect health-related information for many years and store them in a confidential manner. Analyses can then be done by researchers seeking to identify trends or changes in the health of many HIV-positive people. Observational databases have been used to examine what happens to people over the long term, examining outcomes such as overall health, the occurrence of specific illnesses or conditions, and survival. Observational HIV databases, because of the length of time they can monitor participants, have proven to be a valuable source of information that randomized clinical trials, because of their relatively short duration, cannot generally provide.

NA-ACCORD

Researchers in Canada and the U.S. have collaborated to form a giant database called the NA-ACCORD.

When participants initially entered the NA-ACCORD, they saw their doctor at least twice a year. However, in its latest publication, the NA-ACCORD team focused on HIV-positive participants who, after entry to the database, did not appear to be fully engaged with their HIV care. Specifically, the researchers sought data on participants who had infrequent laboratory tests -- that is, waiting more than one year to see a physician to request such testing. For this analysis, the researchers examined data collected between January 2000 and December 2008 from 61,438 participants. The data were collected from the following places:

Canada

Alberta

British Columbia

Québec

U.S.

Alabama

California

Colorado

Florida

Georgia

Illinois

Maryland

Michigan

Missouri

New York

North Carolina

Ohio

Oregon

Pennsylvania

Tennessee

Texas

Washington

Washington, DC

Results

According to the researchers, about 25% of participants had what was called "incomplete retention" or "out of care" episodes (not visiting their doctor to incite referral to a laboratory for blood testing at least once within a 12-month period) at their local clinics. This figure is substantial, representing roughly 15,000 HIV-positive people.

Participants with one or more of the following factors or characteristics were more likely to be out of care:

injected street drugs

had not taken ART

had been under medical care for longer

were Black

Results -- Trends in Time

Over time, the overall proportion of participants who were not engaged in regular (at least once yearly) visits to their doctor fell from nearly 40% in 2000 to 18% in 2008.

Among Canadian participants, the figures were as follows:

year 2000 -- 24% were not in regular care

year 2008 -- 19% were not in regular care

The reason for the increase in lab tests (and visits to doctors) over time was not clear from the present study.

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